Procedures most frequently performed by South African-trained general surgeons – implications for training and assessment
The traditional approach to training and assessment has focused on lists of knowledge objectives. This contrasts with the newer competency-based medical education (CBME) approach, which aims to ensure that all graduates attain the minimum required standards for unsupervised practice in their field. Workplace-based assessment (WBA) has been defined as “the assessment of working practices based on what trainees actually do in the workplace, and predominantly carried out in the workplace itself.” To facilitate WBA within a CBME context, the concept of entrustable professional activities (EPAs) were introduced by Ten Cate in 2005. One of their key characteristics is that they define the core activities that professionals of that discipline are expected to perform. In a process driven by the SA Committee of Medical Deans and the Colleges of Medicine of South Africa (CMSA), the implementation of CBME is envisioned to begin with the introduction of WBA, using an EPA framework, across all postgraduate disciplines from 2024.
Short-stay hospitalisation for thyroid surgery – a feasible option in a resource constrained community
Goitre, characterised by enlargement of the thyroid gland, is one of the most common endocrine disorders worldwide. It is relatively common in Nigeria, with the incidence varying in different parts of the country, similar to varying rates across countries on the African continent, and with various aetiologies postulated.
Perioperative antibiotic practices amongst otorhinolaryngologists (ear, nose and throat surgeons) in South Africa
The primary goal of perioperative antibiotic therapy is to reduce the rate of surgical site infections (SSI), defined as a local infection that occurs within 30 days of surgical incision or organ manipulation during surgery, or within a year of prosthetic implantation. However, in certain surgical procedures the use of perioperative antibiotic therapy has been shown to have no impact on the rate of SSI. Irrational and inappropriate use of antimicrobials not only comes at increased cost and increased risk of side effects to the patient, but also promotes antimicrobial resistance (AMR). AMR is, arguably, one of the greatest current and future threats the health sector faces globally, accounting for approximately 700 000 deaths in 2016, projected to rise to 10 million by 2050. Further to the commonly quoted potential side effects of antibiotics (e.g. gastrointestinal, anaphylaxis, candidiasis), more recent associations with antibiotic overuse reported in the literature include increased risk of obesity, diabetes, inflammatory bowel disease and asthma.
Late presentation of Bochdalek hernia in children – experience at a single centre
Bochdalek hernias (BH) are recognised as a congenital defect present at birth, and this classification holds regardless of when symptoms appear. While most cases are identified within the first 24 hours of life – during which there’s a high mortality risk – about 10% may be detected after the newborn period. Cases identified after one month are considered "late presenting" BH. The concept of late presenting BH has been acknowledged since a pivotal study in 1959, with subsequent research exploring various clinical and diagnostic methods. Patients with late presenting BH tend to have a more favourable outlook, often because there are no significant associated abnormalities, or the hernia has a less severe effect on lung development (such as pulmonary hypoplasia) and doesn’t lead to pulmonary hypertension. Symptoms in these patients can be mild, including respiratory issues, chronic lung infections, pleural effusions, pneumonia, feeding problems, or gastrointestinal disturbances, which vary based on the extent of organ displacement and other complications. X-rays, often performed due to symptoms or discovered by chance, are instrumental in diagnosing some of these cases. However, misdiagnosis can lead to significant morbidity.
Symptomatic omphalomesenteric duct anomalies in children
The omphalomesenteric duct (OMD) is an embryonic structure that connects the yolk sac to the primitive gut and contains vessels that provide nutrition to the developing embryo. Normally, it involutes in utero by the sixth to the ninth week of foetal life and the placenta takes over as the primary source of foetal nutrition. Failure that develops at any point during this process results in a spectrum of anomalies including Meckel’s diverticulum (MD), umbilical fistulas, sinus tracts, polyps, cysts, and congenital bands. Proximal part persistence of OMD, known as MD, was the first to be described and named by Johann Friedrich Meckel, a German anatomist, in 1809.3 MD is the most common remnant of the OMD, accounting for 67– 90% of all cases and is also one of the most common congenital anomalies of the digestive tract in children (2–4%).
Role of multidetector computed tomography-based component separation index in the management of large ventral hernias
Ventral hernia accounts for 10% of all hernias. Results of laparoscopic ventral hernia mesh repair (LVHR) are depicted to be better when they are associated with defect closure. Repair of large complex ventral hernias with loss of domain can be problematic as the hernia contents may not be replaced in the peritoneal cavity. This may lead to abdominal compartment syndrome or acute respiratory failure. Ramirez et al. in 1990 popularised the component separation (CS) technique for repair of these complex ventral hernias5 which is based on the concept of reestablishing a functional abdominal wall with an autologous tissue repair. CS today is described with both open and laparoscopic approach with and without mesh reinforcement.
Serum albumin nadir as marker of inflammatory response in abdominal trauma
Abdominal injuries pose a significant challenge due to their potential for severe complications. Activation of the inflammatory cascade, while essential for the healing process, can also exaggerate tissue damage, leading to systemic complications. Being able to monitor the magnitude of the inflammatory response may offer clinicians the ability to respond to the threat of complications more timeously.
The accuracy of white cell count and C-reactive protein in diagnosing acute appendicitis at a tertiary hospital
Acute appendicitis (AA) is the most common abdominal non-trauma surgical emergency and often the most challenging to diagnose. Worldwide AA remains the most common intra-abdominal condition requiring surgical intervention. There is a noted steady decline in the incidence of appendicitis since the 1940s. Annually, up to 250 000 cases of appendicectomies are reported in the US, with an estimated lifetime risk of 7%. The overall lifetime risk of developing AA is 8.6% for males and 6.7% for females. In Africa, the lifetime risk is 2% as compared to the USA at 9% and Europe at 8%. It occurs most commonly between the ages of 10–30 years, with a male preponderance.
Solitary fibrous tumour presenting as intussusception
A 49-year-old male with no comorbidities presented with acute colicky lower abdominal pain for one day, alongside three months of intermittent abdominal pain, loose stools, and melena. A contrast-enhanced computed tomography scan revealed an intussusception. During exploratory laparotomy, an ileo-ileal intussusception with a 3 cm polypoid lesion 10 cm from the ileo-caecal junction was found. The intussusception was reduced, followed by ileal resection and anastomosis. Histopathology and immunohistochemistry (positive for STAT6, CD34, Vimentin, and SMA) confirmed a solitary fibrous tumour (SFT) of the ileum. The patient recovered well and was discharged eight days postoperatively. He is on annual follow-up.
Pneumatosis intestinalis – an illusive disease
A 69-year-old male patient presented to the emergency department of our hospital with complaints of progressively worsening abdominal pain, accompanied by abdominal distension and an absence of bowel movements over the preceding five days, while still passing flatus. On further enquiry, he admitted to an initial episode of non-bloody, non-mucoid diarrhoea, followed by a brief period of normal stool passage, after which constipation ensued. The patient’s medical history was notable for tobacco use and arterial hypertension controlled using a single agent (angiotensin receptor blocker). The patient was afebrile with normal vital signs and his abdominal examination revealed diffuse tenderness, with no signs of peritonitis. Laboratory analyses revealed a white blood cell count of 16 000/microliter, comprising 77% neutrophils, a C-reactive protein level of 48 mmol/dL and lactate dehydrogenase (LDH) of 180 IU/L. Coagulation values and renal and liver function tests were within normal limits. Arterial blood gas analysis on room air indicated a pH of 7.37, pO2 of 87 mmHg, pCO2 of 40 mmHg, bicarbonate (HCO3) of 22 mmol/L and a serum lactate concentration of 1.5 mmol/L.
A case report on lingual schwannoma
A 24-year-old female presented with a 10-year history of a mass at the base of the tongue. There was associated odynodysphagia, left side referred otalgia and loss of weight. She had no associated dysphonia, gustatory disturbance or evidence of upper airway obstruction. Oral cavity examination revealed a large mass on the left side of the base of the tongue extending into the vallecula, with no impairment of lingual mobility, and no associated cervical lymphadenopathy. The initial clinical impression was of a large submucosal tumour. Contrast-enhanced computed tomography (CT) scan revealed a heterogeneously enhancing mass at the base of the tongue on the left side, measuring 40 mm x 40 mm x 20 mm. There was extension anteriorly to the posterior third of the true tongue abutting the left lateral pharyngeal wall and prestyloid parapharyngeal space. A magnetic resonance imaging (MRI) was ordered for better soft tissue delineation, increased tissue contrast and spatial resolution. The mass was hypointense on T1 weighted image (Figure 1), and hyperintense on T2 weighted image with post-contrast enhancement. Additional features suggestive of lingual schwannoma demonstrated on MRI included a split fat sign (thin peripheral rim of fat on T1WI), a target sign (central low signal within the lesion), and a fascicular sign (multiple internal small ring-like structures). There was no associated cervical lymphadenopathy or evidence of distant metastases.
Adult small bowel volvulus – a case series
Patient 1: A 36-year-old male presented with a 5-day history of right iliac fossa pain, constipation and abdominal distension. He had no known comorbidities and no history of previous operations. Clinically he was acutely ill with a tachycardia and signs of dehydration, but not pyrexial. Examination of the abdomen revealed gross distention and generalised peritonitis. Blood gas analysis revealed a metabolic acidosis and formal laboratory bloods an acute renal injury (urea of 18.6 mmol/l [reference range 2.1–7.1 mmo/l] and a creatinine of 114 umol/l [reference range 64–104 umol/l] as well as an elevated C-reactive protein of 304 mg/l (reference range < 10 mg/l) but a normal white cell count of 6.76 x109/L. Multiple dilated loops of small bowel with air fluid levels were noted on abdominal x-ray. The clinical diagnosis was severe acute appendicitis with a paralytic ileus.
Endoscopy-induced complication of barotrauma with concomitant benign pneumoperitoneum
A 74-year-old female presented to a regional state hospital with lower gastrointestinal (GIT) bleeding and low haemoglobin (Hb). She was known to have hypertension on hydrochlorothiazide for the last twenty years and a history of nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis. On presentation, she had haematochezia with fresh clots per rectum but did not have haematemesis. Her blood pressure was 137/82 mmHg, and her heart rate was 87 beats per minute. She had a Glasgow Coma Scale (GCS) of 14 and her Hb was 5.3 g/dL. She responded to initial intravenous fluid resuscitation with Ringer’s lactate solution and intravenous proton pump inhibitor administration. Her Hb stabilised after transfusion of two units of packed red blood cells to 8.2 g/dL and her GCS was 15. She was prepared for an upper endoscopy and bowel preparation was administered for a lower endoscopy on the next available operating theatre list, due to a congested emergency theatre. On upper endoscopy, Los Angeles grade B oesophagitis, Hills grade III hiatal hernia and antral gastritis were noted. Insufflation-induced barotrauma in the lesser curve around the gastroesophageal junction (GOJ) was found during the procedure. Findings of the barotrauma, as illustrated by the arrows in Figure 1, were linear mucosal tears greater than 3 cm in size that were not present during the initial insertion of gastroscope. No features of perforation were noted, and no other pathologies were found to account for the gastrointestinal bleed.